Medicare Advantage is a private health insurance plan that is an alternative to Original Medicare. These plans, also known as Medicare Part C, include the same coverage as Medicare Part A and Part B (Original Medicare) and may include other coverages, such as vision, dental, and prescription drugs. Some types of Medicare Advantage plans also include no-cost extras, such as wellness programs.
These plans are regulated by the U.S. government but are sold by approved private insurance companies. Signing up for a Medicare Advantage plan typically requires the following steps:
- Ensuring you meet the eligibility criteria
- Waiting for the next applicable Medicare Advantage Enrollment Period
- Comparing Medicare Advantage plans available in your area
- Enrolling in your chosen Medicare Advantage plan
- Receiving confirmation of your coverage
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Why Consider Medicare Advantage? You May Get More Benefits
Medicare Advantage plans are quite popular. In 2022, 48% of individuals eligible for Medicare (28 million people) were enrolled in Medicare Advantage plans.
The average eligible person can access approximately 39 different plan options, so individuals can choose a plan that fits their unique needs and budgets. Each plan may have different expenses, out-of-pocket limits, prior authorization requirements, and benefits.
Medicare Advantage plans may also be less expensive when compared to Original Medicare.
On average, individuals who opted for Medicare Advantage spend $2,000 less per year on premiums and out-of-pocket costs. In addition, those with Medicare Advantage plans may receive more benefits. Currently, 89% of MA plans include prescription drug coverage, and 99.9% include supplemental benefits.
When enrolling in a Medicare Advantage plan, follow these five steps.
1. Make Sure You Meet the Eligibility Criteria
The first step in purchasing a Medicare Advantage plan is ensuring you’re eligible. To enroll in a Medicare Advantage plan, you must meet the following requirements:
- Be eligible for Original Medicare (Part A and Part B)
- Live within the chosen plan’s service area (based on your county)
Generally, people with permanent kidney failure, also known as end-stage renal disease (ESRD), are not eligible to join a Medicare Advantage plan.
2. Mark Your Next Applicable Enrollment Period for Medicare Advantage
There are specific times during the year when individuals can enroll in a Medicare Advantage plan. The Initial Enrollment Period occurs when you’re first eligible for Medicare or when you turn 65. After that, you must wait for the Annual or Special Enrollment Periods and must qualify. Understanding these timeframes and planning ahead can help ensure you don’t miss your window of opportunity.
Enrollment Period | When Is It? | What Can You Do? |
|---|---|---|
Annual Enrollment Period | October 15 through December 7 each year | Add a Medicare Advantage plan if you only have Original Medicare, Switch Medicare Advantage plans. |
Medicare Advantage Open Enrollment Period | January 1 through March 31 each year | Switch or drop your Medicare Advantage plan, if you are already enrolled. |
Special Enrollment Period | Varies, based on your circumstances | Switch or join a Medicare Advantage plan. |
Unwinding Special Enrollment Period | Varies, based on when Medicaid eligibility ends | Enroll in Medicare Part A and Part B, Enroll in Part C after enrolling in Part A and Part B. |
Initial Enrollment Period
The initial enrollment period begins three months before the month of your 65th birthday, includes your birthday month, and extends for three months following. During that time, you can enroll in Original Medicare (Part A and Part B) or enroll in Medicare Part C (a Medicare Advantage plan).
Annual Enrollment Period
The Annual Enrollment Period occurs each year between Oct. 15 and Dec. 7. During this time, you can switch to Medicare Advantage plan if you currently only have Original Medicare. You can also switch from one Medicare Advantage plan to another.
Medicare Advantage Open Enrollment Period
The Medicare Advantage Open Enrollment Period allows individuals currently enrolled in a Medicare Advantage plan to switch or drop their plan and return to Original Medicare. This Medicare Advantage annual enrollment takes place between Jan. 1 and March 31. Note that you cannot enroll during this time if you do not currently have a Medicare Advantage plan.
Special Enrollment Period
Special Enrollment Periods (SEPs) occur when an individual has had a qualifying change in life circumstances. If you qualify for an SEP, you’re able to join an MA plan or switch plans during the specified period, which may be outside of the standard enrollment periods.
Some of the events that could trigger an SEP include:
- Moving to a new address that is not in your plan’s service area
- Losing your employer-sponsored health coverage
- Losing your retiree health coverage
- Losing your Medicaid eligibility
- Losing your Medicare Advantage or Prescription Drug Plan (PDP) coverage
- Being diagnosed with or treated for a chronic health condition
- Qualifying for the Extra Help program to pay for Medicare prescription drug costs
- Enrolling in a Medicare Savings Program
- Moving back to the United States after living abroad
- Gaining U.S. citizenship or lawful presence
Unwinding Special Enrollment Period
When the COVID-19 pandemic began, the U.S. government made significant changes to eligibility and enrollment rules pertaining to Medicaid, allowing more individuals to retain health insurance coverage. However, these changes are ending in 2023. As a result, up to 15 million adults risk losing their health insurance coverage.
States may begin disenrolling people who no longer qualify for Medicaid beginning on April 1, 2023. Some people who were enrolled in Dual Eligible Special Needs Plans (D-SNPs) based on their eligibility for both Medicare and Medicaid may find that they are no longer eligible once they are disenrolled from Medicaid. This may trigger a Special Enrollment Period.
3. Compare Medicare Advantage Plans in Your Area
You can explore your Medicare Advantage plan options online at Medicare.gov. Remember that plans can vary significantly, so you may need to look at several different options before you find one that works for your budget and lifestyle. When comparing your options, consider the following essential points.
Costs
Several factors contribute to the overall cost of a Medicare Advantage plan. These include:
- Premiums: This is the amount you pay the insurance company for your coverage. These payments are due regardless of whether you have covered medical expenses.
- Deductibles: This is the amount of your covered health costs you must pay out of pocket before your plan begins to pay.
- Copayment: This is a set dollar amount you must pay for specific services. For example, you may pay $10 for each doctor’s visit.
- Coinsurance: This is a percentage of the covered healthcare expenses you must pay after you pay your deductible. For example, you may be required to pay 20% of your medical bill.
- Maximum out-of-pocket (MOOP) cost: This is the annual limit on your out-of-pocket costs each year, including your deductibles, copayments, and coinsurance (premiums are not included). In 2023, the MOOP for MA plans is $8,300, but some plans may have lower maximums.
Health Network
In addition to a Medicare Advantage plan’s costs, it’s also important to consider the plan’s network. The two most common types of Medicare Advantage plans are Health Maintenance Organizations (HMO) and Preferred Provider Organizations (PPO).
An HMO plan requires you to visit in-network doctors and other healthcare providers except when you need emergency care or are out of the area. Some HMO plans allow you to get services out of network for a higher cost, but it’s important to follow the plan’s rules to help ensure you don’t have to pay more than necessary. When you choose an HMO, you also typically need a primary care provider and may need a referral for specialist care.
PPO plans also have a network of healthcare providers, doctors, and hospitals. It’s typically less expensive if you stay in-network. However, you also have the option to choose out-of-network providers, typically at a higher cost. A PPO also allows you to see a specialist without a referral.
As you compare your options, consider whether you currently have preferred healthcare providers and if they are covered by your plan. Also, consider whether you have health conditions that may require seeing a specialist frequently.
Benefits
Although private insurance companies offer them, the U.S. government regulates Medicare Advantage plans. Each MA plan is required to provide the same benefits as Original Medicare. However, many Medicare Advantage plans offer additional benefits, sometimes at no extra cost.
For example, many MA plans include Medicare prescription drug coverage (Medicare Part D). Plans may also include dental care, vision care, eyeglasses, hearing aids, and wellness plans. Some offer a flex card, which works like a prepaid credit card and can be used for costs such as over-the-counter health items, groceries, or utilities.
Comparing a Medicare Advantage plan’s extra benefits can help you choose one that fits your health and lifestyle needs.
4. Enroll in Your Chosen Medicare Advantage Plan
Once you’ve selected a Medicare Advantage plan, there are several different ways to enroll. You can enroll online at Medicare.gov. by selecting “Enroll” for the plan you want to join and following the prompts.
If you prefer, you can contact the insurance company directly by visiting its website or calling its customer service phone number. You may be able to enroll over the phone or request a paper enrollment form. Just be sure to thoroughly complete the form and return it before the enrollment period ends.
You can also enroll in a Medicare Advantage plan by calling 1-800-MEDICARE (1-800-633-4227). TTY users can call 1-877-486-2048.
Finally, if you would like assistance with comparing your options and completing your enrollment, you may choose to work with a trusted Medicare agent. Some individuals prefer this option since an agent can provide additional guidance throughout the process.
5. Receive Confirmation of Your Coverage
Once you’re enrolled in a Medicare Advantage plan, you typically receive a confirmation letter within about ten days of completing your application. This letter states that your application has been received, and Medicare has approved your enrollment in the MA plan. You can use this letter to prove your coverage until your membership ID arrives. You’ll receive a Membership ID card shortly after you receive your letter.
The date your coverage begins depends on which enrollment period you are using. For example, during Initial Enrollment, your benefits begin on the first day of the month you turn 65 if you enrolled during the three months prior. If you sign up after your birthday, benefits begin the first day of the following month.
During the Annual Enrollment Period, the new plan benefits begin on Jan. 1 of the following year. If you enroll during the Medicare Advantage Open Enrollment Period, benefits begin the first day of the month after you enroll.
What Happens If You Change Your Mind?
If you enroll in a Medicare Advantage plan and find that you’re unhappy with it, you have some options. You can change plans during the Medicare Advantage Open Enrollment Period (Jan. 1 to March 31) or during the Annual Enrollment Period (Oct. 15 to Dec. 7).
If it’s your first year in a Medicare Advantage plan, you can also drop out of the plan and return to Original Medicare with or without a Medigap plan if the following apply:
- It’s the first time you have been enrolled in an Advantage plan AND
- You joined the plan when you first enrolled in Medicare at age 65 OR
- You had a Medigap policy, which you dropped to join the Advantage plan
If a five-star plan becomes available in your area, you can switch to it anytime during the year except for the first week in December. You are allowed to take advantage of this option once per year.
What This Means for You
Enrolling in a Medicare Advantage plan isn’t difficult, but it does require some planning. First, it’s important to confirm your eligibility and understand the enrollment periods. Then, you need to compare your options, considering important points like benefits, provider networks, and costs.
Once you enroll, look for your confirmation letter and membership card, which you can present to your healthcare providers and pharmacy when receiving services.
You may find that it’s beneficial to work with a trusted Medicare agent who can guide you through the process and help you choose the plan that is appropriate for your budget and your needs. An agent can also help you enroll in your chosen plan and confirm your coverage.